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Physicians often don’t act on poor cardiovascular control
Thousands of patients are dying of cardiovascular disease because physicians fail to treat them appropriately and aggressively with effective medications.
This simple but powerful message is driving new, national performance measurement initiatives on beta-blocker use after heart attacks and control of hypertension and cholesterol, and prompting medical groups around the country to establish cardiovascular quality improvement programs.
With cardiovascular care falling behind the science of medicine, medical groups need to rethink their prescribing practices and develop screening and outcomes management tools, cardiovascular experts say.
This "failure-to-prevent" syndrome presents a major public health problem, says Gideon Bosker, MD, assistant clinical professor at Yale University School of Medicine in New Haven, CT, and author of Pharmatecture: Minimizing Medications to Maximize Results. "Physicians are committing millions of patients unwittingly to the placebo group," he says. "For a number of reasons, individuals at risk for or who have heart disease are not being extended the life-prolonging benefits of drug-based prevention." Bosker asserts that physicians should customize their pharmacologic approach based on a patient’s individual risk factors and, when appropriate, construct multiple "[drug] cocktails for cardioprotection that address the entire spectrum of an individual’s risk factors. These regimens may consist of only a single prescription ingredient, such as a beta-blocker or statin," he adds. "But more often, a mixture of medications and/or nutritional supplements may be required to provide comprehensive cardioprotection."
To assess the full pharmacoeconomic impact of drug-based prevention of heart disease, outcomes measures should be broadened beyond mortality or hospitalization for myocardial infarction to include such issues as the need for invasive diagnostic procedures, angioplasty, or coronary artery bypass graft, and the development of congestive heart failure, says Bosker.
Physicians also need practical help identifying and monitoring their at-risk patients, including follow-up related to compliance and lifestyle changes. "It’s not that doctors don’t know that this is important," says Thomas H. Lee, MD, medical director of Partners Community Health Care, an integrated delivery system in Boston. "It’s that there aren’t systems there to support them."
Many physicians would be surprised to discover how poorly their patients’ cardiovascular conditions are controlled. When the National Committee for Quality Assurance (NCQA) in Washington, DC, tested its upcoming performance measure on hypertension, it found that only 32% to 42% of patients with hypertension had been brought below the target of 140/90 mm Hg.
In a recent study of 800 hypertensive men at five Department of Veterans Affairs sites, about 40% had blood pressure of 160/90 or greater despite an average of six hypertension-related visits per year. Physicians increased drug therapy in only 6.7% of visits.1 Another study found that almost 90% of women with heart disease were not brought within the goals of the National Cholesterol Education Project.1
In his own practice, Lee conducted an informal survey and reviewed patient charts in an urban clinic where he works. He found that only 20% of the patients with hypertension were within the target range. "Often it’s wishful thinking on the part of the physician that blood pressure will come under control [with patient lifestyle changes and without further medication]," he says. Lee, an internist and cardiologist, is co-chair of the Cardiovascular Measurement Advisory Panel for the NCQA, editor of the Harvard Health Letter, and associate professor at the Harvard University School of Medicine.
Now, he assigns a nurse to follow up with patients on education and lifestyle issues as well as compliance with medication therapies and further monitoring.
In fact, nurse involvement can be crucial both in reviewing charts before a patient visit and providing follow-up afterward. Some programs have established special clinics to work with patients on ongoing monitoring and lifestyle issues. (See related stories, pp. 52-59.)
"All of the successful programs that produce good outcomes and good compliance have nurse case managers [to provide follow-up]," says Rodman Starke, MD, executive vice president for science and medicine of the American Heart Association in Dallas. "They’re not cheap, but neither is recurrent myocardial infarction or repeat angioplasty."
In the midst of a busy practice, physicians may be more focused on patients’ acute problems than the long-term risks of cardiovascular disease. The asymptomatic nature of cardiovascular disease and its associated risk factors makes the physician’s job even more difficult, says Bosker.
"In many patients, the disease process may be silent, as it is in silent ischemia or hypertension," he says. "As a rule, people don’t come to their physicians with dramatic symptoms suggesting that their blood pressure is up or that their low-density lipoprotein (LDL) cholesterol is not at goal or that their platelets are too sticky."
Moreover, Bosker points out, "It may not be reasonable to expect patients to buy into a rather abstract trade-off, in which we ask them to comply with costly cardioprotective medications that may have side effects in exchange for the theoretical benefit of added life expectancy years down the road."
Physicians know that the numerical warning signs may foretell serious consequences, but the impact of high blood pressure or high cholesterol evolves over many years. That lack of immediate pressure for action makes less aggressive treatment seem more palatable.
"If we really systematize the evaluation of patients and try to link patients with drug therapy that we know can improve outcomes, and we do so with the vigilance that we might apply to vaccinations or nutritional counseling for the pregnant woman or cancer markers, we will prevent people from falling through the cracks," says Bosker.
Whether medical groups use simple data collection forms or sophisticated computer programs, physicians need to receive ongoing information about how they are managing their patients, says Randall Stafford, MD, PhD, an internist and assistant professor of medicine at Massachusetts General Hospital/Harvard Medical School in Boston.
"Most physicians would have almost no idea what percentage of their congestive heart failure patients are taking ACE inhibitors," says Stafford, who has studied the national use of ACE inhibitors, warfarin, beta-blockers, and other cardiovascular medications. "To provide them with that feedback is really doing a service to physicians. To the extent that they’re compared with their colleagues, it does provide a great incentive to improve practice."
Confusion about old medicine vs. new scientific evidence may also lead to underuse of medications.
Until recently, certain contraindications led to cautious use of beta-blocker therapy among diabetics, the elderly, individuals with chronic obstructive pulmonary disease, and patients with congestive heart failure. But as outlined in a recent Quality Care Alert, issued by the American Medical Association and other medical societies in December, beta-blockers are still beneficial for many of those patients. (See copy of alert, inserted in this issue.)
"The carry-over of that fear about potential complications with such agents as beta-blockers in certain patient subgroups has deterred physicians from being aggressive with those drugs," says Bosker.
Studies also demonstrate that ACE inhibitors reduce mortality for patients with congestive heart failure. The use of ACE inhibitors among patients with congestive heart failure grew in the early 1990s, but only rose to 31% by 1994.2 "Despite the new findings, there’s a tradition about how congestive heart failure is treated," notes Stafford. "The health care system may be very slow to change."
Using physician leaders and pharmacists to promote the new guidelines may increase their adoption, he says. But Stafford notes that physicians may be influenced by claims from pharmaceutical firms about competing medications that aren’t necessarily evidence-based. "It may be necessary to hold the pharmaceutical industry to a higher standard of accuracy in some of their promotions," he suggests.
Patient attitudes can affect their compliance with medication regimens — and physician attitudes about adding drugs to address various risk factors.
"There are so many medications that are available and shown to be useful in cardioprevention; it’s gotten to the point where patients may be taking four or five or even eight different medications," says Bosker.
Physicians need to consider cost, compliance, side effects, and potential drug interactions, he says. "Many of them don’t want to increase the number of drugs in an already complicated regimen. If you streamline the drug regimen, then cardioprotection becomes manageable. And if you identify high productivity’ medications — such as amlodipine, aspirin, beta-blockers, or atorvastatin — which can manage one or more risk factors for an extended period of time without the need for add-on medications, then cocktails for cardioprotection’ will be safer, more effective, and better tolerated."
Medical groups have developed various methods to improve patient compliance, from writing "contracts" on lipid management to simple but persistent reminders from physicians. "A little encouragement makes such a difference," says Starke. "’Are you on your diet? Are you still taking your pills?’"
At Massachusetts General’s anticoagulation clinic, lab technicians visit patients’ homes every month or two to draw blood to monitor warfarin use. Nurses follow up with patients by phone or postcard. That helps avoid the problem of patients who begin treatment but don’t return for follow-up — who may simply slip through the cracks, says Stafford.
"That’s a real fear on the part of primary care physicians, that often we really only keep careful track of patients who come back to see us," he says. "It may be just as important or more important to know what’s happening with people who miss their appointments."
1. Bosker G. Cocktails for cardioprotection. Physician’s Therapeutics & Drug Alert 1999; 4:Supplement.
2. Stafford RS, Saglam D, Blumenthal D. National patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure. Arch Intern Med 1997; 157:2,460-2,464.